What is the significance of Middle Cerebral Artery (MCA) territory infarcts on the inferior frontal and parietal lobes?

From the Guidelines

MCA territory infarcts on the inferior frontal and parietal lobes are a serious condition that can lead to significant morbidity and mortality, and prompt recognition and management are crucial to improve outcomes. Key points:

• Location: Inferior (lower) portions of the frontal and parietal lobes
• Blood supply: Middle cerebral artery (MCA)
• Cause: Blockage or reduced blood flow in the MCA Potential effects:
• Language problems (if in the dominant hemisphere, usually left)
• Difficulty with spatial awareness and sensory processing
• Weakness or paralysis on the opposite side of the body
• Cognitive impairments Management typically involves:

1. Immediate stroke treatment (if acute) such as clot-busting drugs or thrombectomy
2. Secondary prevention with antiplatelet therapy (e.g., aspirin 81mg daily)
3. Blood pressure control (target <130/80 mmHg)
4. Cholesterol management (e.g., high-intensity statin like atorvastatin 40-80mg daily)
5. Rehabilitation focused on affected functions (speech, motor, cognitive therapy) According to the 2018 guidelines for the early management of patients with acute ischemic stroke 1, patients with large territorial supratentorial infarctions, such as those in the MCA territory, are at high risk for complicating brain edema and increased intracranial pressure. In patients ≤60 years of age with unilateral MCA infarctions who deteriorate neurologically within 48 hours despite medical therapy, decompressive craniectomy with dural expansion is reasonable because it reduces mortality by close to 50%, with 55% of the surgical survivors achieving moderate disability or better at 12 months 1. Understanding the MCA's territory helps predict symptoms and guide treatment, and the inferior frontal lobe contains areas crucial for language, while the parietal lobe processes sensory information and spatial awareness, emphasizing the importance of prompt recognition and management. The evidence from the 2018 guidelines 1 and other studies, such as the Swiss recommendations for decompressive craniectomy for space-occupying hemispheric and cerebellar ischemic strokes 1, highlights the significance of MCA territory infarcts on the inferior frontal and parietal lobes and the need for prompt and effective management to improve outcomes.

From the Research

Clinical Significance of MCA Territory Infarcts

The Middle Cerebral Artery (MCA) territory infarcts on the inferior frontal and parietal lobes can have significant clinical implications, including:

• Motor outcome prediction: Studies have shown that diffusion tensor tractography of the corticospinal tract can be used to predict motor outcome in patients with large MCA territory infarcts 2.
• Language disturbances: Infarcts in the left inferior frontal lobe and temporo-parietal lobe can cause transcortical mixed aphasia, characterized by reduced spontaneous speech, impaired object naming, word fluency, comprehension, reading, and writing, but preserved repetition of phonemes and sentences 3.
• Cognitive and behavioral changes: MCA territory infarcts can result in changes in personality, judgment, motor synchronization disturbances, disorientation, hemianopia, or hemineglect, depending on the affected artery 4.

Anatomical and Etiological Considerations

The MCA territory includes the greater part of the lateral surface of the cerebral hemisphere and is divided into 12 areas supplied by 12 different arteries 4. Anatomical variations should be considered in these infarcts. The etiology of MCA territory infarcts can be embolic, with cardiac embolism being a common cause, or due to large-artery disease, such as carotid artery or MCA stenosis or occlusion 5.

Diagnostic and Therapeutic Implications

Diagnosis of MCA territory infarcts can be made using imaging techniques such as MRI, MRA, and CT scans. Mechanical thrombectomy can be an effective treatment for acute ischemic stroke caused by MCA occlusion, even in the presence of rare anomalies such as duplicated MCA 6. A comprehensive neurovascular and cardiological assessment is essential for the correct treatment of patients with MCA territory infarcts 4.